We’ve spent a lot of time discussing the COVID-19 pandemic on this channel, but we should also take a look back down the line at the last major pandemic. We can learn a lot of lessons from history, if we’re willing to listen. Let me tell you about what was called the Spanish Flu Pandemic of 1918-1919. The Spanish Flu was responsible for infecting about a third of the world’s population and killing 50 million people.

First, I think we owe the Spaniards an apology. During WWI, nations involved in the struggle, including the United States, didn’t allow the publication of bad news that could harm the war effort. Things like, say, a highly contagious epidemic. Spain, however, was neutral and didn’t censor the press, so whatever news you got about the new virus was usually from Spanish journalists. The pandemic became known as the “Spanish flu”, since whatever news there was about the virus came out of Spain.

When the Spanish flu first appeared in March 1918, it had all the hallmarks of a seasonal flu, but it soon became recognized as highly contagious and, in some cases, deadly. Some believe the flu started in China, but one of the first cases reported was not in Asia or Europe, but the United States.

He was Albert Gitchell, a U.S. Army cook in Haskell County, Kansas, who was hospitalized with a 104-degree fever. Yep, it’s possible the flu started right here in the U.S.A., although that’s still a point of contention 100 years later. It makes sense that a cook might become infected, as a lot of influenza viruses may mutate from swine and birds used as food-producing livestock.

Anyway, The virus spread quickly through the Army installation, which, at the time, was home to 54,000 troops. By the end of the month, 1,100 troops had been hospitalized and 38 had died after developing pneumonia.

As U.S. troops deployed for the war in Europe in 1917, they carried the Spanish flu with them. Throughout April and May of 1918, the first wave of the virus spread like wildfire through England, France, Spain and Italy. Some sources estimate three-quarters of the French soldiers were infected and half of British troops. Yet the first wave of the virus didn’t appear to be particularly deadly, with symptoms like fever lasting only three days. At first, the death rate was similar to seasonal flu.

By August, people were hopeful the worst was over, but it was really just the end of the first wave. In Europe, a mutated version of the flu emerged later that could kill healthy young adults. This became the second wave and it was deadlier than the first. It spread to the four corners of the Earth as many soldiers headed home as WWI came to a close.

Not to downplay today’s risks from COIVD-19, but From September through November of 1918, the more lethal version of the Spanish flu went out of control. In the United States, 195,000 Americans died from the Spanish flu…. Just in the month of October.

A normal seasonal flu, which mostly claims victims among infants and toddlers, the elderly, and infirm, looks like a “U” if you make a graph out of the age-related numbers. The second wave of the Spanish flu, however, made a graph that looked like a W, because it killed high numbers of 25-35-year-olds. Today, COVID-19 is affecting more people in this age group as the country attempts to reopen. Except for some hot spots, most of these younger cases (so far) are mild or asymptomatic.

The high numbers of Spanish flu deaths in healthy young adults mystified doctors at the time, but we believe now that the deaths were often caused by something known as “cytokine storm.” When the human body is being attacked by a virus, the immune system sends messenger proteins called cytokines to promote helpful inflammation. In the Spanish flu, like COVID-19, this system had a tendency to go haywire, and a massive overload of cytokines causes fatal inflammation in the lungs. Doctors in WWI likened the appearance on autopsy to the effects of gas warfare.

At the time, most public health officials were aware of the Spanish flu outbreaks but were unwilling to impose quarantines. They were concerned it would cripple the economy and, certainly, the war effort.

Physician and nursing shortages due to military enlistments didn’t help, as well as the American Red Cross’s refusal at the time to use African American nurses until very late in the pandemic.

The technology wasn’t sufficient to quell the crisis. We just couldn’t see viruses back then, and health officials were convinced the virus was bacterial in nature. We didn’t get the high tech to visualize viruses until the 1930s.

By December 1918, the deadly second wave of the Spanish flu had finally passed, but a third wave emerged in Australia in January 1919 and traveled back to Europe and the United States. It’s thought that even President Woodrow Wilson may have been infected.

The mortality rate of the third wave was equally as bad as the second wave, but the end of the war in November 1918 removed the conditions that allowed the disease to spread as rapidly. The soldiers were home. Still, millions more died by the middle of 1919, when the Spanish flu finally petered out.

Are there lessons to be learned from the Spanish Flu pandemic of 1918-19? I say to ignore history’s lessons is to repeat its mistakes. You can learn a lot from the past.

Joe Alton MD

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